OGABANG, MARIA JUBEL A.

BSN 2-A2
NURSING RESEARCH 1
SAS 29
CHECK FOR UNDERSTANDING (15 minutes)
Short Quiz. You are to read and analyze the informed consent below then identify the
parts of the informed consent on
the blanks provided by writing the number representing it. Erasures and
superimpositions will be marked wrong. (15
points).
1- Participant status 9- Potential benefits
2- Study goals 10- Alternatives
3- Type of data 11- Compensation
4- Procedures 12- Confidentiality pledge
5- Nature of the commitment 13- Voluntary consent
6- Sponsorship 14- Right to withdraw and withhold
information
7- Participant selection 15- Contact information
8- Potential risk

Informed Consent Form

1 I understand that I am being asked to participate in a research study at Excel
2 Hospital and Medical Center. This research study will evaluate; What it is like being a
mother of multiples during the first year of the infants’ lives. If I agree to participate in
the
3, 3 study, I will be interviewed for approximately 30 to 60 minutes about my experience
as a
4 mother of multiple infants. The interview will be tape-recorded and take place in a
private
5 office at Saint Francis Hospital. No identifying information will be included when the
interview
12 is transcribed. I understand I will receive P5,000.00 for participating in the study.
There are no
11 known risks associated with this study.
7 I realize that I may not participate in the study if I am younger than 18 years of age or I
cannot speak English.
9 I realize that the knowledge gained from this study may help either me or other
mothers of Multiple infants in the future.
13 I realize that my participation in this study is entirely voluntary and I may withdraw
from the
14 study at any time I wish. If I decide to discontinue my participation in this study. I will
Continue to be treated in the usual and customary fashion.
12 I understand that all study data will be kept confidential. However, this information
may be used in nursing publications or presentations.
8 I understand that if I sustain injuries from my participation in this research project. I will
not be automatically compensated by Excel Hospital and Medical Center.
15 If I need to, I can contact Dr. Sheree Ganzon, University of Pangasinan, College of
Nursing, any time during the study.
1,14 The study has been explained to me. I have read and understand this consent
form, all of my Questions have been answered and I agree to participate. I understand
that I will be given a Copy of this signed consent form.

Signature:

MARIA JUBEL A. OGABANG